| Hearing loss (Acoustic Neuroma) | Hearing loss (idiopathic hearing loss) | Noise induced hearing loss (Tinnitus) | |
|---|---|---|---|
| Station | FY2 in GP. A 40yo lady has presented with some concerns. Take a focused history and perform relevant examination | FY2 in GP. 40y0 Robert Adam presented with some hearing problems on the left side. Assess the patient and address his concerns | FY2 in GP surgery. 40yo Elena Jones presented with some concern. Assess the patient and discuss management with the patient. |
| NB/ perform otoscopy and inspection on the mannikin and tuning fork on the patient | NB/ otoscopy normal bilateral, Rinne’s is normal bilateral and Weber’s is localized to the left, bone conduction is fine on the Rt | ||
| Patient info | Hearing loss on the left side for 4months. You also have balance problem, dizziness, and numbness in your face. Your father had a similar condition but you don’t know the problem. You have noticed that when you close your eyes or when it gets dark you become dizzy and unsteady on your feet (Romberg +). Patient must demonstrate sensorineural hearing loss on the left side | Hearing difficulty since yesterday then DrI couldn’t hear anything this morning. You are normally fit and well and not on any regular meds. This is the 1" time it is happening. You work in a telephone communication office and you can’t make any telephone calls | Have ringing in the ear for 4months duration. Work in a factory and it is noisy but you use ear protection there.Worse when you go to bed. Description of the sound buzzing, whistling, sizzles, humming. It presents on both ears |
| Intro | How can I help you today? | ||
| History | Explore hearing loss (complete or partial/ ringing sensation (what does it like? How often does it happen? any particular time?) + Cardinal symptoms | ||
| Concern | Apart from that, what’s your main concern? | ||
| D.D | DD of ear, Red flags: rash, fever, vomiting | ||
| P2 | Have you ever had such condition before? Previous medical conditions | ||
| Đ 3 | DESA, MAFTOSA (occupation) | ||
| Finishing Hx | Thank you for the information you gave me | ||
| Expectations | What do you expect from today’s visit? | ||
| Examination | Observations + Ear (full exam) + throat + Romberg’s test (+) + CN7,8,5 | ||
| Ideas | Do you have any idea what might be causing your hearing loss? | ||
| Provisional diagnosis | It is a growth in the nerve that is responsible for hearing and balance and it comes with hearing loss on the affected side and the other symptoms. It is not cancerous | This happens when there is a damage to the nerve which is responsible for hearing. But the cause is unknown | Noise induced hearing loss as you told me that… It usually improves with time for most people. It is probably due to your work environment |
| Management | Urgent referral to ENT: they would reassess you and perform more investigations like MRI of the brain and Audiometer (special hearing test). if diagnosis is confirmed then surgery is the 1st line as treatment Investigations: Routine bloods CBC Advice: stop driving, don’t go in the dark alone because of balance problem. Safety netting: discharge, fever | Urgent referral to ENT: they would reassess you and perform more investigations like MRI of the brain and Audiometer (special hearing test). Investigations: Routine bloods CBC Advice: stop driving, don’t go in the dark alone because of balance problem, use hearing aids Safety netting: discharge, fever. Talk to the occupational therapist at work | Urgent referral to ENT: they would reassess you and perform more investigations like MRI of the brain and Audiometer (special hearing test). Advise: take time off work or change your job if you can, low level background music to distract tinnitus, stop driving. Safety netting: if persistent |
| Please at any time if you have questions or concerns, let us know | |||
| Questions | Sudden hearing loss: One ear: ear wax, ear infection, perforated TM, Meniere’s disease. Both ears: damage from the very loud noise, taking certain meds. Gradual hearing loss: One ear: something inside the ear (fluids), bony growth (otosclerosis), build up skin cells (cholesteatoma) Both ears: aging, exposure to loud noises over years | Tinnitus is the perception of sound in the absence of sound from the external environment |
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Noise Induced Hearing Loss
Diana Wilson, a 40 year old lady
You have had ringing in ear for the last one month
The noise is worse when she is about to go to bed
You work in a factory which is very noisy but you use ear protection
Examinations:ENT (normal), Tuning fork tests (normal), Romberg’s test (normal)
1. GRIPS
- How can I help?
2. History of presenting complaint
- Nature of tinnitus
- What sort of sound is that?
- How does the ringing in your ear sound like? ď‚· Is it in both ears?
- FODPARA
- Cardinal symptoms
Causes of unilateral tinnitus:
- Meniere’s (DVT): vertigo lasts about 15-24 hours, fullness of ear
- Acoustic neuroma: tinnitus and progressive SNHL, family history
Causes of bilateral tinnitus and SNHL:
- Age related
- Noise induced (occupational)
- Drug induced
Causes of CHL with unilateral or bilateral tinnitus: ď‚· Impacted ear wax
- OM
- Cholesteatoma
- Otosclerosis
Systemic causes of tinnitus: - MS, DM, neck or head injuries, thyroid disease, stress
3. PMAFTOSA
4. ICE
5. Effects
6. Examination
- Observations
- ENT (normal), tuning fork tests (normal), Romberg’s test (normal)
7. Diagnosis
- You have a something called tinnitus, it is hearing noises that are not caused by sounds coming from the outside world, it can be sometimes ringing, buzzing, humming and it is common and not usually a sign of anything serious. The cause is unknown but because you are working in a noisy workplace it could be due to your work, but for most of people it resolves on its own in a few weeks
8. Management
- I do advise you to avoid noise and to relax and relieve any stress in your life, you are doing great by wearing the ear protection at your work but maybe you can discuss this with the occupational department in your workplace to reassess the working conditions and your personal protective equipment
- Reassure that tinnitus is common and improves with time for most people
- Sound therapy by playing a low level background noise as a distraction from the tinnitus
9. Offer leaflet
10. Safety netting
- If you developed any hearing problem, please come back
- Or at any time if you feel that you are very distressed or foundthis very annoying, you can come back to the GP
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